New program meets heart patients where they live. Literally.

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Wednesday, December 27, 2023

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New program meets heart patients where they live. Literally.

Mike Scott, mscott@stph.org

St. Tammany Health System Home Health nurses Jason Green, left, and Daley Harrington, right, visit with Mary and Walter Bahn – along with pooch Minnie – in the Bahns’ Mandeville home. Mary Bahn was one of the first patients in a pilot program designed to reduce the re-hospitalization of patients with congestive heart failure. (Photo by Tim San Fillippo / STHS)

Congestive heart failure patients participating in a new program at St. Tammany Health System are given a refrigerator magnet, funded by St. Tammany Hospital Foundation, to manage symptoms at home through the Transitions of Care Team Program, with the goal of avoiding unnecessary hospitalizations. (Photo by Mike Scott / STHS)

Mary Bahn’s cell phone rang. “I’m out walking the dog right now,” she told the person on the other line.

For her, even that was a personal victory.

Just five months earlier, the simple act of breathing was difficult for the 81-year-old congestive heart failure patient following an episode that landed her on life support at St. Tammany Health System’s flagship St. Tammany Parish Hospital.

Her condition at that point was so dire doctors weren’t sure she’d make it.

But Mary Bahn is made of tougher stuff than that. Not only did she make it, but she has become the poster child for a pilot program launched this past spring by the health system’s Home Health Services team to help congestive heart failure patients more effectively manage their condition.

Working with a patient’s existing care team and collaborating with various STHS departments – from cardiology and primary care to physical therapy and cardiac rehab – the program is built around a combination of remote patient monitoring, patient education, structured patient outreach and regular in-home visits from STHS care providers.

In its first five months, the program has seen 30-day hospital readmissions plummet from a monthly average of nine congestive heart failure patients to fewer than three.

“Education is typically the biggest intervention that we make,” said STHS Nurse Practitioner Jason Green, who has been spearheading the program with nurse Daley Harrington and Post-Acute Navigator Anna Thomas. “Honestly, if people are well-educated on their dietary changes, their lifestyle modifications, we can get ahead of congestive heart failure exacerbations before they even happen.

“We may not have to add medications. We may not have to change a thing. If we can get in there early and effectively change the habits they have, we can avoid an exacerbation and eventually avoid a hospitalization, which is good for everybody.”

For Mrs. Bahn that extra layer of support has been invaluable.

“I might be 81, but I want to be 50,” she said. “I want to be able to do all the things I could.”

That includes walking Minnie, her mystery breed attention hound, and getting back to eschewing the elevator in favor of the stairs to the third-floor Mandeville condo she shares with husband Walter.

To get to that point, the Bahns have been educating themselves on such things as ways to cut the sodium in her diet, something they’ve found help with on YouTube and various Facebook groups, as well as the role sleep habits play in congestive heart failure.

Mrs. Bahn acknowledges she still has headway to make, but there’s no question she’s already come a long way.

“Now, I’m 200% better,” she said. “Probably 300%.”

That’s music to Green’s ears.

“Congestive heart failure is scary, it’s life-changing, it’s a big diagnosis that carries a lot of weight,” he said. “But it’s not the end of the world. We can treat it. Especially at St. Tammany, with this new program, we have the capability to work with your current care team, we have the capability to bring care into your home, and we have the capability to really change the outcome of your care journey.” 

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